[Changes in arterial ketone body ratio (AKBR) in subarachnoid hemorrhage patients]

The arterial ketone body ratio (AKBR) is considered an accurate index of the functional reserve of the liver, and its validity has been confirmed in the field of abdominal surgery. We found low AKBR values subarachnoid hemorrhage patients and discuss the clinical significance of this finding in this paper. Twenty-eight patients with subarachnoid hemorrhage treated at our institution were included in this study. Their ages ranged from 26 to 81 years old (average: 61.5 years). According to the WFNS classification 12 cases were grade I, II, or III, and 16 were grade or IV V. Surgical clipping was performed in 23 of these cases, within 2 days after symptoms of subarachnoid hemorrhage appeared. There were eight cases of symptomatic vasospasm and three cases of re-ruptured aneurysm. Outcome was classified according to the Glasgow Outcome Scale (GOS) as: good recovery (GR), moderately disabled (MD), severely disabled (SD), vegitative survival (VS), and dead (D). Using these criteria, the outcome of these patients was as follows: GR or MD in 10 cases, SD or VS in 8 case, and D in 10 cases. Ten healthy adults were chosen as controls. We collected arterial blood samples on days 1, 2, 3, 7, 10 and 14 after the onset of symptoms (day 0) and measured the following: 1, beta-hydroxybutyrate; 2, acetoacetate; 3, epinephrine; and 4, norepinephrine. On day 0 total ketone body levels were higher (165.6 +/- 119.9 mumol/l), and AKBR values (0.65 +/- 0.24) were significantly lower than in the control group (2.50 +/- 1.09) (p < 0.001), while both epinephrine and norepinephrine levels were significantly higher, 506.5 +/- 200.3 pg/ml and 899.5 +/- 221.4 pg/ml, respectively. The AKBR value was 0.90 +/- 0.27 on day 1, 1.11 +/- 0.4 0 on day 2, and increased thereafter. The average AKBR value exceeded 1.0 on day 2 in the ten GR and MD cases. In the SD and PVS cases, however, it exceeded 1.0 on day 3, but in the D patients it never exceeded 1.0 and instead was significantly lower. AKBR values are known to decrease not only in hepatic failure, but in cases in which the liver energy charge is reduced, such as shock and hypoxemia, but no investigations have ever been performed to determine whether AKBR is altered in cerebrovascular disease. In this study, we found that AKBR values were lower in subarachnoid hemorrhage, presumably due to the reduced hepatic blood flow caused by the increased levels of epinephrine and norepinephrine. In addition, our findings suggested that the fluctuations in AKBR values were correlated with the outcome of subarachnoid hemorrhage patients.